愛滋感染者在高效能抗反轉錄病毒治療後病毒抑制失敗之相關因素

研究目的：為了在2030年達成終結世界愛滋疫情帶來的公共衛生威脅，UNAIDS宣誓2020年達「90-90-90」的治療目標，第三個90是希望90%接受高效能抗反轉錄病毒治療者達病毒抑制，並以治療作為預防策略。本研究透過社會經濟、疾病相關、治療相關及患者相關等四大面向因素來了解接受持續性抗病毒藥物治療者病毒抑制失敗的原因及障礙，研究結果作為國家愛滋病防治政策參考，並提升感染者的健康。研究方法：本研究是以醫院為基礎的病例對照研究，在2017年9月至2018年9月以結構式問卷調查中部地區某醫學中心感染科門診之愛滋病毒感染者。期間共484位符合收案標準，179位拒絕問卷調查，305位完成問卷調查，排除5位缺乏CD4淋巴球及病毒量的報告，總計300位男性納入本研究，問卷調查率達62%，依據病毒量檢測結果分為病毒抑制失敗組75人及病毒抑制組225人。使用統計分析軟體SPSS 22版進行卡方檢定、t檢定、皮爾森積差相關係數、斯皮爾曼等級相關係數、線性迴歸、單變項與多變項邏輯斯迴歸分析，另以Sobel test進行中介效果的驗證。研究結果：影響愛滋病毒感染者病毒抑制失敗的危險因子有:梅毒感染及成癮物質使用；保護因子有:教育年數較高、藥物治療前CD4淋巴球數量≥200 cells/μL、伴侶的疾病揭露及服藥遵從性自我效能分數較高者；具有中介效果的因子有:內化汙名、梅毒感染、身心科相關診斷及迴避傷害人格。而憂鬱症狀不是內化汙名與伴侶疾病揭露的修飾變項，內化汙名獨立預測伴侶的疾病揭露，不受憂鬱症狀的影響。結論：達病毒抑制目標取決於穩定的服藥遵從行為，但服藥遵從行為更多是生理及心理層面等多重因素的影響。本研究以病毒量數據來間接監測是否維持良好服藥遵從性，結果發現病毒抑制失敗受成癮物質使用影響，由成癮物質使用啟動生理與心理因素機制的路徑。

關鍵字

愛滋病毒感染者；高效能抗反轉錄病毒治療；病毒抑制失敗；疾病揭露；內化汙名；梅毒感染；成癮物質使用

並列摘要

Objectives: To put an end to the public health threat caused by the global epidemic situation of AIDS, UNAIDS has committed to achieving the treatment target of “90-90-90” by 2020. The third 90 refers to achieving virus suppression in 90% of people receiving highly active antiretroviral therapy (HAART) and use the therapy as a prevention strategy. This study, through the four factors including: socio-economic, condition-related, therapy-related, and patient-related aspects, investigated causes and obstacles leading to virologic failure in patients receiving sustained HAART. The research findings may serve as a reference for the state’s policy making in HIV prevention and treatment, and improve the health conditions of those infected. Methods: This is a hospital-based, case-control study. Structured questionnaires had been used to survey people with HIV infection at the out-patient clinic of the Infectious Disease Department in a medical center of Central Taiwan between September 2017 and September 2018. During this period, a total of 484 patients met the study requirements. While 179 refused to participate in the survey, 305 completed it. With 5 cases excluded due to lack of reports for CD4 lymphocytes and viral load, a total of 300 male patients were included in this study, giving a survey response rate of 62%. Based on the viral load test results, the cases were divided into two groups, where 75 patients were assigned to the virologic failure group and 225 to the virus suppression group. Statistical analysis was carried out using SPSS (version 22.0) package, we performed Chi-squared test, t test, Pearson product-moment correlation coefficient, Spearman's rank correlation coefficient, linear regression, as well as univariate and multivariate logistic regression analysis. In addition, the Sobel test was used to examine the mediation effect. Results: Risk factors causing virologic failure in patients with AIDS were syphilis infection and the use of addictive substances; protection factors included receiving higher education, CD4 lymphocyte count equal to or more than 200 cells/μL before medication treatment, disclosing HIV status to partner, and higher self-efficacy scores for medication adherence; factors with mediation effect were internalized HIV stigma, syphilis infection, psychiatry related diagnosis and harm avoidance personality. Additionally, depression was not a moderator effect for internalized HIV stigma and disclosure of a partner’s HIV status. Internalized HIV stigma independently predicted the disclosure of a partner’s HIV status, and this was not affected by depression. Conclusion: Achieving virus suppression targets relies on medication adherence behavior, whereas the medication adherence behavior is influenced by multiple physiological and psychological factors. This study used viral load data to indirectly monitor whether there was a good medication adherence; the study found a pathway where the virologic failure was affected by substance use and substance use would activate mechanisms where physiological and psychological factors were involved.

並列關鍵字

people living with HIV ； highly active antiretroviral therapy , HAART ； virologic failure ； disclosure of HIV status ； internalized HIV stigma ； syphilis infection ； substance use